Vitamin D Deficiency
Vitamin DDeficiencyCopyrightCopyright 2019 2019AmericanAmericanAssocia7onAssocia7onof Clinicalof ClinicalEndocrinologistsEndocrinologists1
Vitamin D Vitamin D is a fat-soluble vitamin involved in the regula7onof calcium homeostasis and bone health. It is synthesized inthe body when ultraviolet rays from sunlight strike the skinand trigger vitamin D synthesis. There are few foods that naturally contain vitamin D or arefor7fied with it. The major source of vitamin D for bothchildren and adults is exposure to natural sunlight. Themajor cause of vitamin D deficiency is lack of sun exposure.Holick MF et al. Evalua7on, treatment, and preven7on of vitamin D deficiency: an Endocrine Society clinical prac7ce guideline. J Clin Endocrinol Metab 2011; 96:1911-30.LeFevre M et al. Screening for vitamin D deficiency in adults: U.S. preven7ve services task force recommenda7on statement. Ann Intern Med 2015; 162:133-141.Na7onal Ins7tutes of Health. Vitamin D: Fact Sheet for Professionals. Available at ofessional/. Accessed August 23, 2018.Copyright 2019 American Associa7on of Clinical Endocrinologists2
Defini&ons of Vitamin D Deficiency There is not yet broad consensus on what cons7tutes vitamin Ddeficiency. Different organiza7ons have slightly different defini7ons,based on serum levels of 25-hydroxyvitamin D, or 25 (OH)D.The Endocrine SocietyThe Ins7tute of Medicine(Health and MedicineDivision of the Na7onalAcademies)The Mayo ClinicThe American Associationof Clinical EndocrinologistsDeficiency: 20 ng/mlDeficiency: 12 ng/mlSevere deficiency: 10ng/mlDeficiency: 30 ng/mlInsufficiency: 21-29 ng/mlInsufficiency: 12-20 ng/mlMild to moderateDeficiency: 10-24 ng/mlOptimal: 30-50 ng/mlOptimal: 30 ng/mlOptimal: 20 ng/mlOptimal: 25-80 ng/mlKennel KA et al. Vitamin D deficiency in adults: When to test and how to treat. Mayo Clin Proc 2010; 85:752-758.IOM (Institute of Medicine). 2011 Dietary Reference Intakes for Calcium and Vitamin D. Washington DC: The National Academies Press.Holick MF et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2011; 96:1911-30Camacho PM, Petak SM, Binkley N et al. American Association of Clinical Endocrinologists and American College of Endocrinology Clinical Practice Guidelines for theDiagnosis and Treatment of Postmenopausal Osteoporosis - 2016. Endocr Pract. 2016;22(Suppl 4):1-42.Copyright 2019 American Associa7on of Clinical Endocrinologists3
Consequences of Vitamin D Deficiency Vitamin D deficiency results in abnormalities in calcium,phosphorous, and bone metabolism. Severe and prolongeddeficiency can cause bone mineralization diseases, such asrickets in children and osteomalacia in adults. Vitamin D deficiency has also been associated withfractures, falls, functional limitations, some types of cancer,diabetes, cardiovascular disease, and depression. Howeverthe U.S. Preventive Services Task Force notes that, “theseassociations are inconsistent and may vary by the cut pointused to define low vitamin D levels.”LeFevre M et al. Screening for vitamin D deficiency in adults: U.S. preven7ve services task force recommenda7on statement. Ann Intern Med 2015; 162:133-141.Copyright 2019 American Associa7on of Clinical Endocrinologists4
Prevalence in the United States Using a cutoff of 20 ng/ml, an analysis of Na7onal Healthand Nutri7on Examina7on Survey (NHANES) data from 20052006 found that the overall prevalence rate of vitamin Ddeficiency among U.S. adults was 41.6%. Rates are significantly higher in blacks and Hispanicscompared with whites. In the NHANES study, the highest ratewas seen in blacks (82.1%), followed by Hispanics (69.2%). Even when using a more conserva7ve defini7on, manypa7ents rou7nely encountered in clinical prac7ce will bedeficient in vitamin D.Forrest KY and Stuhldreher WL. Prevalence and correlates of vitamin D deficiency in U.S. adults. Nutr Res 2011; 31:48-54.Kennel KA et al. Vitamin D deficiency in adults: When to test and how to treat. Mayo Clin Proc 2010; 85:752-758.LeFevre M et al. Screening for vitamin D deficiency in adults: U.S. preventive services task force recommendation statement. Ann Intern Med 2015; 162:133-141.Copyright 2019 American Associa7on of Clinical Endocrinologists5
Symptoms of Vitamin D Deficiency Vitamin D deficiency is often asymptomatic. However,severe or prolonged deficiency may cause the followingsymptoms: Bone discomfort or pain in the lower back, pelvis, orlower extremities Falls and impaired physical function Muscle aches Proximal muscle weakness Symmetric low back pain (in women)Bordelon P et al. Recogni7on and management of vitamin D deficiency. Am Fam Phys 2009; 80:841-846.Copyright 2019 American Associa7on of Clinical Endocrinologists6
Who Should be Screened? Neither the Endocrine Society, the Mayo Clinic, the U.S. Preven7ve Services Task Force, nor the AmericanAssocia7on of Clinical Endocrinologists recommends universal screening for vitamin D deficiency amongthe general popula7on or asymptoma7c individuals. However, they do recommend screening inindividuals with risk factors for vitamin D deficiency. These include the following: Malnutri7on Sedentary Lifestyle Limited sun exposure Obesity Dark skin Age 65 Condi7ons causing gastrointes7nal malabsorp7on, including short bowel syndrome, pancrea77s,inflammatory bowel disease, amyloidosis, celiac sprue, and bariatric surgery. Liver disease or failure Renal insufficiency or nephro7c syndrome Cys7c Fibrosis Medica7ons that alter vitamin D metabolism, including an7convulsants and glucocor7coidsKennel KA et al. Vitamin D deficiency in adults: When to test and how to treat. Mayo Clin Proc 2010; 85:752-758.Holick MF et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2011; 96:1911-30Bordelon P et al. Recognition and management of vitamin D deficiency. Am Fam Phys 2009; 80:841-846.LeFevre M et al. Screening for vitamin D deficiency in adults: U.S. preventive services task force recommendation statement. Ann Intern Med 2015; 162:133-141.Copyright 2019 American Associa7on of Clinical Endocrinologists7
Diagnosis There is broad consensus that diagnosis of vitamin D deficiency shouldbe made using a reliable assay for 25(OH)D. Testing for serum 1,25dihydroxyvitamin D is not recommended. Available methods include competitive protein binding, immunoassay,high performance liquid chromatography, and combined highperformance liquid chromatography and mass spectrometry. The U.S. Preventive Services Task Force cautions that the sensitivity andspecificity of these tests are unknown due to the lack of studies using aninternationally recognized reference standard. Variability between assaymethods and even between laboratories using the same method mayrange from 10% to 20%. Classification of samples as deficient or normalmay vary by 4% to 32%.Kennel KA et al. Vitamin D deficiency in adults: When to test and how to treat. Mayo Clin Proc 2010; 85:752-758.Holick MF et al. Evalua7on, treatment, and preven7on of vitamin D deficiency: an Endocrine Society clinical prac7ce guideline. J Clin Endocrinol Metab 2011; 96:1911-30Bordelon P et al. Recogni7on and management of vitamin D deficiency. Am Fam Phys 2009; 80:841-846.LeFevre M et al. Screening for vitamin D deficiency in adults: U.S. preven7ve services task force recommenda7on statement. Ann Intern Med 2015; 162:133-141.Copyright 2019 American Associa7on of Clinical Endocrinologists8
Treatment of Vitamin D Deficiency There is broad consensus that increased intake ofdietary vitamin D is not enough to correct deficiency.Vitamin D supplementa7on is required. Vitamin D2 orD3 are recommended.Kennel KA et al. Vitamin D deficiency in adults: When to test and how to treat. Mayo Clin Proc 2010; 85:752-758.Holick MF et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2011; 96:1911-30Bordelon P et al. Recognition and management of vitamin D deficiency. Am Fam Phys 2009; 80:841-846.LeFevre M et al. Screening for vitamin D deficiency in adults: U.S. preventive services task force recommendation statement. Ann Intern Med 2015; 162:133-141.Copyright 2019 American Associa7on of Clinical Endocrinologists9
Treatment: Endocrine SocietyRecommendations Age 0-12,000 IU per dInfants and Toddlers ay or 50,000 IU once weekly for 6 weeks to achieve ablood level 25(OH)D above 30 ng/ml. Followed by maintenance therapy of 400-1,000IU/day. Children Age 1-182,000 IU per day for at least 6 weeks or 50,000 IU once weekly for at least 6 weeks toachieve a blood level 25(OH)D above 30 ng/ml. Followed by maintenance therapy of 6001,000 IU/day. Adults6,000 IU per day or 50,000 IU per week for 8 weeks to achieve a blood level 25(OH)Dabove 30 ng/ml. Followed by maintenance therapy of 1,500-2,000 IU/day. Special CasesObese patients, those with malabsorption syndromes, and those on medications affectingvitamin D metabolism should receive a higher dose of 6,000 to 10,000 IU/day to achievelevels above 30 ng/ml. Followed by a maintenance dose of 3,000-6,000 IU/day.Holick MF et al. Evalua7on, treatment, and preven7on of vitamin D deficiency: an Endocrine Society clinical prac7ce guideline. J Clin Endocrinol Metab 2011; 96:1911-30Copyright 2019 American Associa7on of Clinical Endocrinologists10
Preven&on: Endocrine SocietyRecommenda&ons The Endocrine Society recommends the following daily intakes of vitamin Dto prevent deficiency and maximize bone health. Children age 0-1: at least 400 IU/day. May require 1,000 IU/dayto achieve 30ng/ml Children age 1-18: at least 600 IU/day. May require 1,000 IU/dayto achieve 30ng/ml Adults age 19-70: at least 600 IU/day. May require 1,500-2,000 IU/dayto achieve 30ng/ml Adults older than 70: at least 800 IU/day. May require 1,500-2,000 IU/dayto achieve 30ng/ml Obese children and adults; those on an7convulsant medica7ons,glucocor7coids, and an7fungals such as ketoconazole; and those takingmedica7ons for AIDS should be given at least two to three 7mes more vitaminD for their age group to sa7sfy their body’s requirement.Holick MF et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2011; 96:1911-30Copyright 2019 American Associa7on of Clinical Endocrinologists11
Prevention: AACE Recommendations Daily supplementation with vitamin D3 at a dose of1,000 to 2,000 IU is typically needed to maintain anoptimal serum 25(OH)D level. Higher doses may be necessary in the presence ofcertain factors including obesity, malabsorption,and certain ethnicities. Transplant patients andolder individuals may also need higher doses.Camacho PM, Petak SM, Binkley N et al. American Associa7on of Clinical Endocrinologists and American College of Endocrinology Clinical Prac7ceGuidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis - 2016. Endocr Pract. 2016;22(Suppl 4):1-42.Copyright 2019 American Associa7on of Clinical Endocrinologists12
Preven&on: Ins&tute of MedicineRecommenda&ons Children and adults age 1-70: 600 IU per day Adults older than 70: 800 IU per dayIOM (Institute of Medicine). 2011 Dietary Reference Intakes for Calcium and Vitamin D. Washington DC: The National Academies Press.Copyright 2019 American Associa7on of Clinical Endocrinologists13
Vitamin D Toxicity Excess vitamin D supplementation can lead to hypercalcemia, but vitamin Dtoxicity is extremely rare. It generally occurs only after ingestion of large dosesof vitamin D ( 10,000 IU/day) for prolonged periods in patients with normalgut absorption or those ingesting excessive amounts of calcium. Patients with vitamin D toxicity can present with clinical symptoms ofhypercalcemia, including nausea, dehydration, and constipation, or symptomsof hypercalciuria such as polyuria and kidney stones. The lowest reported 25(OH)D level associated with toxicity in patients withoutprimary hyperparathyroidism and with normal renal function is 80 ng/ml.Most patients with vitamin D toxicity have levels greater than 150 ng/ml. One dosing study reported that vitamin D supplementation with 1,600 IU/dayor 50,000 IU monthly was not associated with any laboratory parameters oftoxicity and even failed to increase total 25(OH)D levels above 30 ng/mL in19% of participants.Kennel KA et al. Vitamin D deficiency in adults: When to test and how to treat. Mayo Clin Proc 2010; 85:752-758.Copyright 2019 American Associa7on of Clinical Endocrinologists14
major cause of vitamin D deficiency is lack of sun exposure. Holick MF et al. Evalua7on, treatment, and preven7on of vitamin D deficiency: an Endocrine Society clinical prac7ce guidel ine. J ClinEndocrinolMetab2011; 96:1911-30. LeFevre M et al. Screening for vitamin D deficiency in adults: U.S. preven7ve services task force recommenda7on .
Konsumsi asam folat, vitamin B12 dan vitamin C pada ibu hamil tergolong masih rendah, sehingga konsumsi sumber vitamin perlu ditingkatkan untuk mencegah masalah selama kehamilan, seperti anemia, prematur, dan kematian ibu dan anak. Kata kunci: asam folat, ibu hamil, vitamin B12, vitamin C *Korespondensi: Telp: 628129192259, Surel: hardinsyah2010@gmail.com J. Gizi Pangan, Volume 12, Nomor 1 .
Milk Thistle Red Clover Rhodiola St. John’s Wort Soy Bean Tomato Tribulus Terrestris Willow Vitamin B1 Vitamin B2 Vitamin B6 Vitamin B12 Vitamin C Vitamin D3 Vitamin E MISCELLANEOUS Alpha Lipoic Acid Beta Carotene Caffeine Choline Bitartrate Chond. Sulphate Bovine Chond. Sulphate Porcine Ch
Normal vitamin D 36% 9% 55% Vitamin D deficiency* Severe vitamin D deficiency** Normal vitamin D Camargo CA, Jr., Ingham T, Wickens K, et al. Vitamin D status of newborns in New Zealand. Br J Nutr 2010;104:1051 -7. Grant CC, Wall CR, Crengle S, Scragg R. Vitamin D deficiency in early childhood Public Health Nutr. 2009;12(10):1893-1901
Peak E ciency Power Added E ciency (PAE) is a popular metric. P out is the output power, P in is the input power, and P dc is the DC power consumption of the PA For high power gain systems (G p), the e ciency approaches the drain drain e ciency ( d), or for a BJT, the \collector" e ciency, or simply the e ciency of the last stage
7.6 The role of vitamin A in vision 151 7.7 Retinoids as regulators of gene expression 155 7.8 Effects of vitamin A on the immune system 171 7.9 Role of vitamin A in bone metabolism and embryonic development 174 7.10 Vitamin A and cancer 176 7.11 Vitamin A defi ciency and toxicity 178 Further reading 180 References 180
25-OH Vitamin D levels* To determine vitamin D status * Only measure if patient is symptomatic and has risk factors for Vitamin D deficiency. Measurement, status and management (see Appendix 1 for flowchart) Vitamin D level Vitamin D status Health effect Management 30 nmol/L Defi
VITAMIN A This vitamin helps your body maintain healthy eyes and skin. VITAMIN C This vitamin helps the body heal cuts and wounds and maintain healthy gums. VITAMIN E This vitamin helps maintain healthy cells throughout your body. WATER Water makes up more than half of your body weight. Your
important.1 But the form of the vitamin D in it is. Look for supplements that contain: Vitamin D3, which is superior at optimizing and maintaining vitamin D levels long-term2 3 Or, if you prefer a plant-based option: Vitamin D2, which is derived from yeast or mushrooms For best absorption, take vitamin D with a meal, especially one that .
